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National malaria microscopy competency assessment and accreditation course:

Facilitator’s manual for Zambia

Note: Zambia’s national program was the first under the MalariaCare project to implement a national malaria microscopy competency assessment program to assess routine malaria

microscopists. The program was adapted from the World Health Organization External Competency Assessment of Malaria Microscopy course. Other countries may find such an exercise useful for

building competency in malaria microscopy and strengthening quality assurance systems. In such cases, this example may be adapted for the specific context.

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Contents

1.0 Introduction to the malaria microscopist competency assessment ......................................................... 1

1.1 WHO external competency assessment overview ................................................................................. 1

1.2 Zambian Competency Assessment overview ........................................................................................ 2

2.0 Introduction to the national competency assessment facilitator’s manual ................................................. 3

2.1 Aim of this manual ................................................................................................................................ 3

2.2 Goal ....................................................................................................................................................... 3

2.3 Objectives .............................................................................................................................................. 3

3.0 Role of the facilitator .................................................................................................................................. 4

3.1 Facilitator responsibilities ..................................................................................................................... 4

3.2 Using this guide ..................................................................................................................................... 4

4.0 Preparing for the workshop ........................................................................................................................ 5

4.1 Workshop duration ................................................................................................................................ 5

4.2 Plan with national and subnational authorities ...................................................................................... 5

4.3 Participant selection and characteristics ................................................................................................ 5

4.4 Venue selection and length of course .................................................................................................... 5

4.5 Required supplies, equipment, and materials ........................................................................................ 5

4.6 Course agenda and timetable ................................................................................................................. 6

4.7 Calendar of activities for preparation .................................................................................................... 6

5.0 Course monitoring and evaluation .............................................................................................................. 8

6.0 National competency assessment course structure ..................................................................................... 9

6.1 Training methods ................................................................................................................................... 9

6.2 Course structure overview ..................................................................................................................... 9

7.0 Pre-assessment overview .......................................................................................................................... 11

7.1 Theory-based knowledge .................................................................................................................... 11

7.2 Blood film preparation ........................................................................................................................ 11

7.3 Malaria microscopy ............................................................................................................................. 11

8.0 Assessment overview ............................................................................................................................... 13

8.1 Assessing participant preparation of thick and thin blood films ......................................................... 13

8.2 Assessing participant malaria microscopy competency ...................................................................... 14

8.2.1 Proposed slide sets for the microscopy competency assessment ................................................ 14

8.2.2 Conducting the malaria microscopy assessment ......................................................................... 14

8.2.3 Scoring the malaria microscopy assessment ............................................................................... 15

9.0 Final scoring ............................................................................................................................................. 16

10.0 Annexes .................................................................................................................................................. 17

Annex 1. Equipment and reagents required for training ........................................................................... 17

Annex 2. Learning units ............................................................................................................................ 19

Annex 3. Resources ................................................................................................................................... 23

1

1.0 Introduction to the malaria microscopist competency assessment

1.1 WHO external competency assessment overview

In 2005, the World Health Organization (WHO) Regional Offices for the Western Pacific and South-East Asia

and partners including the Asian Collaborative Training Network for Malaria and the Research Institute for

Tropical Medicine (Philippines) developed a bi-regional program to accredit malaria microscopy

competency.1 Since 2011, external competency assessments (ECAs) have been conducted in more than 14

countries, including a number of countries in the Africa region. A major objective of the ECA is to assist

national malaria programs in building capacity for national or reference-level core groups whose skills can be

utilized both in country and regionally.

The objectives of the ECA are:

1. Help to develop a national core group of expert microscopists in participating countries who are

accredited to internationally recognized standards for malaria microscopy. This group would ideally form

a multi-country or regional network that can be used for training and accreditation initiatives.

2. Provide formal certification of the competency of microscopists, to:

a. Provide recognition of individual skill level thus providing acceptability for cross-checking and

training programs.

b. Standardize practices between countries performing malaria microscopy and standardize monitoring

activities.

c. Increase self-esteem of microscopists and confidence among providers and users of diagnostic results,

and provide well-defined and attainable goals.

d. Advocate to link results to a career structure.

Since the scope and audience of the ECA are very specific and participation is limited to 12 individuals per

course (drawing from multiple countries at one time), the ECA is not an appropriate method to use to assess

the competency of routine malaria microscopists. Therefore, the National Malaria Elimination Center is

establishing procedures and standards to assess the competency of routine malaria microscopists through a

nationally recognized accreditation program called the Zambian Competency Assessment.

1 Ashraf S, Kao A, Hugo C, Christophel EM, Fatunmbi B, Luchavez J, Lilley K, Bell D. Developing standards for

malaria microscopy: external competency assessment for malaria microscopists in the Asia-Pacific. Malaria Journal.

2012;11:352. doi: 10.1186/1475-2875-11-352.

2

1.2 Zambian Competency Assessment overview

As mentioned above, the objectives, methods, and assessment criteria used to develop the national

competency assessment (NCA) were based on the WHO ECA program. While there is significant overlap

between program objectives, major differences are associated with the intended audience and the stringency of

the assessment criteria.

The major objectives of the NCA are to:

1. Help to identify a core group of national experts who will lead training at both the national and provincial

levels.

o Selection should be based on their national accreditation scores, their relative ability to do well in the

ECA (goal is to attain an ECA score of Level 1 or Level 2), and their capacity to function as a trainer

of trainers.

2. Establish and certify a group of subnational (provincial) microscopy trainers who can perform health

facility quality assurance visits.

o This cadre of supervisors should demonstrate high-quality and consistent microscopy skills over time.

3. Assess and certify skills of lead microscopists working in any health facility where malaria microscopy

services are offered.

o This cadre of lead microscopists should demonstrate skills at a high enough level to train subordinates

within their facility and practicing microscopists at lower-level health facilities.

4. Establish and certify basic minimum competencies for laboratory staff performing malaria diagnosis at the

referral and peripheral levels.

o In order to ensure microscopy quality, the course will seek to accredit microscopists based on a

minimum standard necessary to perform high-quality microscopy.

5. Advocate to link results to a career structure.

This manual outlines the major components and implementation of the NCA.

3

2.0 Introduction to the national competency assessment facilitator’s manual

2.1 Aim of this manual

This facilitator’s manual is designed to support implementation of the NCA and to familiarize facilitators with

the objectives and methods for assessment, grading, and communication of final results to participants.

2.2 Goal

The goal of this guide is to facilitate a well-planned NCA workshop.

2.3 Objectives

The objectives of this manual are to:

Provide an overview of the NCA course, including content, learning units, and teaching/assessment

methodologies applied in this course.

Create a NCA package that includes specific documents and tools that will be used by facilitators and

participants.

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3.0 Role of the facilitator

3.1 Facilitator responsibilities

The NCA lead facilitator is a WHO-certified Level 1 (expert) or Level 2 microscopist with significant

teaching experience in malaria diagnostic methods and quality assurance. Co-facilitation can be supported by

highly experienced trainers with known competency in malaria microscopy. The facilitator is responsible for

implementing high-quality education on malaria microscopy and creating an environment for participants to

thrive during examination. The facilitator will be responsible for assessing both the qualitative and

quantitative aspects of the NCA. In order to successfully accomplish his/her responsibilities, it is critical that

the course content, course structure, and training skills are mastered prior to the workshop.

The facilitator will be responsible for troubleshooting problems (logistical and technical) that may arise during

the workshop and identifying solutions in order to minimize disruption. The facilitator also will contribute to

the overall cohesion of the class and be able to assess if the concepts or instructions are fully understood and

when they are not. It is important that the facilitator creates an environment in which participants feel

comfortable to freely ask questions and actively participate in discussions around NCA objectives.

Specific responsibilities include:

Communicate the importance of the NCA.

Explain and demonstrate interpersonal communication skills.

Give clear instructions during training and assessments and verify participants’ understanding.

Manage time during the NCA by starting and ending on time and completing all modules and assessments

outlined in the course.

Ensure that participants remain attentive, involved, and engaged.

Provide participants with constructive feedback during training to motivate and improve their

performance.

Evaluate the skills and competency of each participant.

3.2 Using this guide

This guide should be used during both the planning and implementation phases of the course.

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4.0 Preparing for the workshop

This section describes the various activities and concepts the facilitator needs to consider when planning the

course.

4.1 Workshop duration

The course is conducted over five consecutive days.

4.2 Plan with national and subnational authorities

It is important to communicate training plans and intentions with planners at both the national and subnational

levels, as their approval and endorsement of the activity is critical for strong attendance and implementation.

These communications are especially important when identifying and selecting the most appropriate

participants. In addition, it is helpful to understand the different possible logistical constraints from province

to province (e.g., availability of equipment or supplies, power supply).

4.3 Participant selection and characteristics

The identified staff should be working mainly in the malaria/parasitology section of the laboratory and

performing routine malaria microscopy. Health facilities such as central and provincial-level hospitals that

serve a large proportion of the population may be given the highest priority.

4.4 Venue selection and length of course

An appropriate venue should be chosen based on the following specifications:

A room that can accommodate both teaching and practical laboratory work, or separate rooms for teaching

and practical laboratory work.

One functioning microscope available per participant.

Electricity and/or access to a reliable and well-fueled power generator.

A facility to provide morning and afternoon tea and lunch to the participants.

Transport to collect additional supplies and secretarial assistance.

Access to printing and photocopying is an added advantage.

Nearby accommodations for facilitators and participants.

4.5 Required supplies, equipment, and materials

Supplies and equipment should be organized well in advance of the training. Microscope quality should be

inspected by the facilitators to ensure that all necessary components are available (e.g., 100X immersion oil

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objective, etc.). Extra microscope bulbs should be kept on hand. A list of equipment, supplies, and reagents

required for this training can be found in Annex 1.

4.6 Course agenda and timetable

In order to carry out a successful NCA, it is critical that facilitators become familiar with the course agenda. If

there is more than one facilitator, it will be important to identify which learning units will be conducted by

which facilitator based on areas of expertise. Assessment exercises should be well planned the evening before.

In order to become familiar with the course, it is important to review the sequence of all learning and

assessment modules.

The following activities should be conducted in order to become familiar with the course content and

structure:

Review the curriculum and assessment requirements.

Review the timetable and plan ahead for practical assessments.

Decide on the number of participants (ideally not to exceed 20).

Determine the space needed (lecture and laboratory space) to accommodate participants.

Confirm the number of facilitators and responsibilities for each facilitator.

Decide which modules each facilitator will teach.

Review the list of supplies, equipment, and other materials required and initiate procurement.

Consider the time it will take each day/evening to grade daily malaria microscopy competency

assessments.

Plan other activities, such as opening and closing ceremonies, certification, and follow-up.

Table 1 on the following page outlines the course agenda and timetable.

4.7 Calendar of activities for preparation

A well-conceived work plan and calendar outlined with clear roles and responsibilities is essential for

staying organized and prepared. Each facilitator should consult both the work plan and calendar to see

which activities he/she was assigned.

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Table 1. Accreditation course agenda.

Time Monday Tuesday Wednesday Thursday Friday

8:30-9:00 Opening remarks Review slides Review slides Review slides Review slides

9:00-10:00 ❶Introduction to NCA ❸Diagnostics overview ❼Artifacts,

pseudoparasites, and

mixed infections

❽Microscopy quality

assurance

Distribution of final

grades

10:00-11:00 Theoretical

pre-assessment

❹Preparing blood films ❾The microscope

11:00-11:15 Tea break Tea break Tea break Tea break Tea break

11:15-12:15 Slide preparation

pre-assessment

❺Staining with Giemsa Slide preparation

assessment

Microscopy examination

review – open for questions

Small group

discussions on

training gaps,

impression of the

course

12:15-1:15 ❷Review of slide

preparation quality

standards

❻Examining blood films Plenary sessions

(group

presentations)

1:15-2:15 Lunch Lunch Lunch Lunch Lunch

2:15-5:15 Malaria microscopy

pre-assessment

Malaria microscopy

assessment Day 2

Malaria microscopy

assessment Day 3

Malaria microscopy

assessment Day 4

Closing remarks and

participant

departure 5:15-5:45

Tea break and facilitator

meeting


meeting


meeting


meeting

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5.0 Course monitoring and evaluation

This course utilizes a 360-degree approach to assessment, meaning the course participants are evaluated as

well as the facilitators.

Overall evaluation of course participants

Pre-assessments (theory and practical).

Observation by facilitators.

Daily competency assessments to measure performance in slide reading during the course.

Post-assessments.

Course evaluation by participants

At the end of the course, the participants will be asked to fill out a standard evaluation form. The evaluation is

conducted anonymously and addresses both technical and logistical issues.

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6.0 National competency assessment course structure

The NCA can be opened by a representative from the central level; for example, from the National Malaria

Elimination Center or the National Reference Laboratory. The opening statement should be given by a well-

respected opinion leader who is recognized nationally in the field of malaria diagnostics in order to increase

the motivation of the participants. Additionally, this individual should effectively express the strong interest

and commitment of the Minister of Health in the NCA program.

6.1 Training methods

The facilitators will need to become familiar with the different training methods used during this course. Each

method will require a specific approach in terms of logistics and preparation.2 It is expected that each

facilitator will apply the relevant communication skills and knowledge to each training/assessment method.

The major learning tools used during this course are as follows:

Pre-assessments: To measure baseline knowledge of theory and slide preparation.

Learning units: Composed of a lecture using a corresponding PowerPoint presentation.

Competency assessments: For preparation of malaria blood films and malaria and malaria microscopy.

This activity requires advanced planning during facilitator meetings.

Facilitator meetings: To review the day’s activities, troubleshoot any problems, plan for the next day’s

activities, assemble slide sets, and grade the daily microscopy assessment.

Post-assessments

6.2 Course structure overview

The NCA will be conducted over a period of five consecutive days and is composed of both learning and

assessment modules. The learning modules will be didactic and focus on the baseline knowledge participants

possess and seek to improve upon. Pre-assessment of relevant malaria theoretical knowledge, blood film

preparation, and malaria microscopy will occur on Day 1. Days 2 through 4 will comprise both learning units

(Annex 2) and assessment modules for preparing malaria blood films and malaria microscopy assessment of

skills (detection, species identification, and parasite quantitation). Final grades will be presented on Day 5,

and group discussions will be held on how to implement lessons learned once participants return to their field

work. Table 2 below provides an overview of assessments that will require planning, such as preparation of

slides or reagents the day before.

2 World Health Organization, Special Programme for Research and Training in Tropical Diseases. Course Facilitators

Guide: Training of Trainers on Malaria Diagnostic Testing using RDTs. Draft; May 2013.

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Table 2. Overview of assessments.

Day 1 Pre-assessment

Day 2 Assessment

modules

Day 3 Assessment

modules

Day 4 Assessment

modules and grading

Theoretical

Slide preparation Slide preparation

Slide reading Slide reading Slide reading Slide reading

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7.0 Pre-assessment overview

All pre-assessments will be administered on Day 1 and be used to gather baseline information on both

individuals and the group.

7.1 Theory-based knowledge

Microscopists should be familiar with both the diagnostic aspects of malaria as well as the Plasmodium

parasite lifecycle, how infection causes disease, and have a basic understanding of treatment for both

uncomplicated and severe malaria infection. The pre-course test is in multiple choice format and is used to

assess the group’s underlying knowledge base. The results will be used by the instructor to provide targeted

learning during didactic lectures on Day 1 and for practical instruction during Days 2 through 4. Theoretical

knowledge base, however, will not be part of the course final grade.

7.2 Blood film preparation

A pre-course assessment will be conducted to evaluate individual and group skill levels related to preparing

thin and thick blood films. The instructor will make note of common errors on participants’ pre-assessments

and address these identified issues during specific learning modules. Course participants will conduct a self-

assessment of their blood films to become familiar with the ten quality standards that will be used by

facilitators to compute their final assessment score.

Each participant will prepare two blood films on one slide, one thick film and one thin film, and submit the

slide for grading. Each film will be scored against standard criteria (see Table 4 in Section 8.0) and be worth

10 points. Both film scores will be combined into a composite score by adding the results for the thick and

thin films together. The maximum number of points possible for this exercise is 20 (10 points for each film).

The next morning, participants will assess their own slides using the standard criteria, prior to receiving their

final score from the instructor.

7.3 Malaria microscopy

Baseline scores will be obtained for malaria microscopy skills based on parasite detection, species

identification, and slide preparation. Each participant will read a total of 19 unique slides and be given ten

minutes per slide. Facilitators will use the table below to create the pre-assessment slide sets (one slide set per

participant).

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Table 3. Pre-assessment slide set composition.

Pre-assessment slide set

#

unique

slides

# slides parasite

detection Species ID # of counting slides

Plasmodium falciparum (Pf)

Plasmodium vivax (Pv)

Placental malaria (Pm)

9 5 slides of:

2 Pf 50-100 p/µl

1 Pf 100-200 p/µl

1 Pv (density N/A)

1 Pm (density N/A)

5 slides of:

Same as in previous

column

4 slides of:

1 Pf 500-1,000 p/µl

1 Pf 5,000-10,000 p/µl

1 Pf 10,000-50,000 p/µl

1 Pf 50,000-100,000 p/µl

Negative 7 7 - -

Mixed:


Plasmodium ovale (Po)

3 3 3 slides of:

Pf/Po (density N/A)

-

Total # unique slides 19 15 8 4

Results will be returned the following morning for a detailed review using the microscope. Participants also

will be given one hour to review their answers against the slides.

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8.0 Assessment overview

Assessments will be conducted over a period of three days (Days 2‒4). The assessment component is

composed of two parts:

1. Preparation of thick and thin blood films.

2. Microscopy slide reading skills and assessment of skills (parasite detection, species identification, and

parasite quantitation).

A composite score based on results from the three daily assessments will be provided on the final day of the

course.

8.1 Assessing participant preparation of thick and thin blood films

Each participant will be assessed on ability to prepare good-quality blood films. The thick and thin films will

be prepared on the same slide. Each slide will be assessed on the ten quality standards listed in Table 4.

Each quality standard is worth 1 point, for a composite score of 10 points per film. Participants will prepare

two blood films, one thick film and one thin film, and submit for grading. The maximum number of points

that can be scored for this exercise is 20.

Table 4. Ten quality standards for malaria blood films.

Quality standards for malaria blood films #1 #2 Total

1 Is the blood film labeled correctly?

2 Is the thick film of adequate size (~10 mm in diameter) or 90% intact?

3 Does the thick film have correct the thickness? (Can you read it through

newsprint?)

4 Are the white blood cells in the thick film properly stained? (Nuclear material

should be purple.)

5 Are the red blood cells in the thick film completely lysed?

6 Does the thin film have a feathered edge?

7 Do the red blood cells appear in a single layer at the feathered edge?

8 Do the red blood cells show correct staining? (Color should be pink.)

9 Is the parasite stained correctly? (The cytoplasm is stained blue and the chromatin

appears as a pinkish dot.)

10 Do both the thin and thick smears have transparent backgrounds (i.e., debris does

not interfere with a normal reading of each)?

Individual film scores

Composite slide score

Scoring: 17/24 points (>85 percent correct) is required to pass this component.

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8.2 Assessing participant malaria microscopy competency

Participants will be assessed on parasite detection (absence/presence of parasites), species identification, and

counting (parasite density measured in parasites/microliter). Each slide will be examined for a maximum of

ten minutes under strict “examination conditions.” Participants must not communicate in any way with any

person other than an examiner.

8.2.1 Proposed slide sets for the microscopy competency assessment

Facilitators will need to assemble slide sets for each day for all participants (this should be done prior to the

start of the course). The slide sets will be used to assess different skills, such as parasite detection, species

identification, and parasite quantitation. The slide sets will comprise a different number of slides and

composition, including negatives, species, and density.

8.2.2 Conducting the malaria microscopy assessment

Tables 5 and 6 below provide a breakdown of the total number of slides that will be examined each day by

category (e.g., number of slides examined for parasite detection, number of slides examined for parasite

identification, and number of slides examined for counting). Again, it is important to assemble slide sets

before the course begins or each evening in order to avoid serious delays.

As mentioned above, malaria microscopy assessments will be conducted during Days 2 through 4. Each

participant will receive one slide set.

Slide sets for Days 2 and 3 are composed of 19 unique slides each. Participants will be responsible for reading

38 slides over the two-day period. For assembling slide sets for assessment Days 2 and 3, use Table 5.

Table 5. Day 2 and Day 3 slide set composition.

Days 2 and 3 assessment

slide set

#

unique

slides

# slides parasite



Plasmodium vivax (Pv)


9 5 slides of:

2 Pf 50-100 p/µl

1 Pf 100-200 p/µl

1 Pv (density N/A)

1 Pm (density N/A)

5 slides of:

Same as in previous

column

4 slides of:

1 Pf 500-1,000 p/µl

1 Pf 5,000-10,000 p/µl

1 Pf 10,000-50,000 p/µl

1 Pf 50,000-100,000 p/µl

Negative 7 7 - -

Mixed:



3 3 3 slides of:

Pf/Po (density N/A)

-


The slide sets for Day 4 are composed of 18 unique slides each. For assembling slide sets for assessment Day

4, use Table 6 below.

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Table 6. Day 4 slide set composition.

Day 4 assessment slide set

#

unique

slides

# slides parasite





8 2 slides of:

1 Pm 50-100 p/µl

1 Po (density N/A)

2 slides of:

Same as in previous

column

4 slides of:

1 Pf 500-1,000 p/µl

1 Pf 5,000-10,000 p/µl

1 Pf 10,000-50,000 p/µl

1 Pf 50,000-100,000 p/µl

Negative 6 6 - -

Mixed:



4 4 4 slides of:

Pf/Po (density N/A)

-


8.2.3 Scoring the malaria microscopy assessment

A composite score for the malaria microscopy assessment is tallied by summing results from Days 2, 3, and 4.

For instance, a composite score will be calculated for each microscopy skill, such as parasite detection,

species identification, and parasite quantification, using data from Days 2, 3, and 4. The final score is

converted into a percentage by dividing the number of correct answers by the total number of slides examined

and multiplying by 100. Table 7 provides detail on the scoring for this assessment, as well as roles for each

level of accreditation and actions to be taken based on assessment results.

Parasite detection: Slides for which there is agreement on presence or absence of parasites, divided by

ALL slides inspected for parasite detection.

Parasite quantification: Slides for counting parasite density within 25 percent of true count (upper or

lower limit), divided by all counting slides.

Species identification: Slides for which there is agreement on species, divided by ALL slides with

parasites.

Table 7. Scores for malaria microscopy assessment.

Level

Parasite

detection

Species

ID

Parasite quantitation

(±25% of true count) Recommended roles Action

Advanced

accreditation

>90% >90% >50% National trainer

OTSS supervisor

Reference laboratory

director/lead technician

Eligible for WHO

accreditation

Basic

accreditation

>80% to

<90%

>70% to

<90%

>40% to <50% Peripheral-level

microscopist

Attends bi-annual

refresher training

Not accredited <80% <70% <40% Peripheral-level

microscopist in need of

remedial training

Prioritized for

remedial training/

work under

supervision

16

9.0 Final scoring

The final assessment score combines results from the two different assessments (preparation of thick and thin

films and the malaria microscopy assessment). The minimum requirement for passing the NCA is a

participant score of >17 for slide preparation and achievement of at least the “basic accreditation” level for

malaria microscopy (see Table 8).

Table 8. Minimum grades for accreditation.

Final course grade

Slide preparation score Microscopy grade Determination

≥17 points correct quality

assurance steps

Advanced accreditation

OR

Basic accreditation

PASS

<16 points correct quality

assurance steps

Advanced accreditation

OR

Basic accreditation

OR

Not accredited

FAIL

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10.0 Annexes

Annex 1. Equipment and reagents required for training

Description Unit Status/Notes

Laboratory equipment and supplies Items received

Electric binocular microscope 1 per participant

Storage box or microscope cover 1 per microscope

Blue filters (if available) 1 per participant

Lint-free tissue 5 boxes

100X immersion oil objective 1 per microscope

Extra bulbs (for microscope) 3-5

Power cords 1 per microscope

Tally counter 2 per participant

Plastic bins for washing hands (if no sink) 5

Slide drying racks 5

Balance or scale for weighing reagents 1 for group

Weighing paper 1 box for group

Frosted microscope slides 5 boxes

Lancets (for rapid diagnostic tests and making blood films)

1-2 boxes (up to 50 lancets)

Timing clock with alarm 1 for group

Alcohol swabs 1 box for group

Cotton wool 1 box for group

Laboratory coats 1 per participant

Gloves 2-5 boxes

Rapid diagnostic tests (and required reagents) 1 per participant

Reagents for stains (solution or powder):

Giemsa stain solution (best quality) 1L bottle

Giemsa stain powder (best quality) 5-10 g

Buffer tablets (pH 7.2) 1 box

Potassium dihydrogen phosphate and disodium hydrogen phosphate (to prepare 100L of buffered water, pH 7.2 if buffer tablets not available)

5L

Methanol 5L

Field stain A and B 500ml of stain A and B

Glycerol 250-500ml bottle

Distilled water 20L

Filter paper (Whatman No. 1) 1 box

Immersion oil (best quality) 1 per microscope

Glassware:

Measuring cylinders 10ml, 100ml, 1L

Slide staining racks/jars 5 racks or jars

Reagent bottles 5 X 250-500ml bottles

Amber bottles 5 X 250-500ml bottles

Glass beads 1 bottle

Glass rods 1 box

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Description Unit Status/Notes

Course equipment and supplies:

LCD projector 1

Laptop computer 1

Pens/pencils 1 per participant

Notebooks/writing tablets 1 per participant

Name tags 1 per participant

World Health Organization malaria microscopy training CD-ROM

1 per participant

Printed course curriculum/PowerPoint slides 1 set per participant

Printed timetables 1 per participant

Printed pre- and post-tests 1 per participant

Certificate paper 1 per participant

Facilitator’s manual 1 per facilitator

Daily attendance sheet 1 per each day of training

Receipts (for tracking per diem) 1 book of receipts

Rapid diagnostic test protocols 1 per participant

Malaria microscopy protocols 1 per participant

Thick and thin blood film template 1 per participant

19

Annex 2. Learning units

Lecture topics are described below and denoted by a solid circle in the agenda.

Unit ❶ Workshop introduction (1 hour)

Format – This session will be delivered as a lecture with slide presentations.

Learning unit key topics

Introduction to course content

Distribution of documents

Learning objectives

Participants introduce themselves

Explain the objectives of the national competency assessment

Establish course expectations for participants

Review the timetable for the course

Unit ❷ Quality standards for malaria blood films (1 hour)



Introduction to the ten quality standards for making malaria blood films

Learning objectives

Review the ten quality standards

Self-assessment of slide quality

Unit ❸ Malaria diagnostics overview (1 hour)



Malaria parasite lifecycle

Importance of parasitological confirmation

Malaria situation in Zambia

Learning objectives

Malaria parasite lifecycle overview

Importance of parasitological confirmation

Rapid diagnostic tests versus microscopy – advantages and disadvantages

Describe the distribution and occurrence of malaria in the world

Describe the epidemiology of malaria in Zambia

Recognize and understand the vectors of malaria in Zambia

Articulate the progress made in malaria control in Zambia

20

Unit ❹ Preparing blood films



Handling potentially infectious blood

Preparing thick and thin blood films on the same slide

Correct labeling of blood films

Blood film quality and common causes of error

Learning objectives

Emphasize and explain why human blood should always be treated as hazardous

Describe the importance of at least four diseases found in infected blood

Demonstrate the necessary precautions to avoid direct contact with potentially infected blood

Describe to learners the materials required for making thin and thick blood films

Describe how to correctly make thick and thin blood films

Demonstrate how to correctly label blood films

Demonstrate how to separate thick and thin blood films of acceptable quality from unacceptable

ones, giving reasons for their rejection

Help participants to identify common faults in thick and thin blood films and their causes

Unit ❺ Staining with Giemsa stain



Use of equipment needed for making Giemsa

Description of how to pH buffer and its importance

Storing and handling Giemsa stain

Learning objectives

Demonstrate correct operation of the balance

Make buffer eater used to dilute Giemsa stain

Demonstrate the correct use of pH paper or pH meter

Make up pH balancing fluids used to adjust pH of buffered water

Explain why pH 7.2 water is best for good Giemsa staining

Explain when rapid and slow Giemsa staining methods are used for malaria microscopy

Describe the correct ways to store and handle Giemsa stain

Describe correct drying and storing of stained slides

21

Unit ❻ Examining blood films



Normal blood components

Methods for slide examination

Recognizing and identifying other blood parasites

Learning objectives

List the four major components of normal blood

Demonstrate each method used for examining a thick and thin blood film for malaria parasites

Recognize and classify the normal components of blood

Name the main parts of a white blood cell

Unit ❼ Artifacts, pseudoparasites, and mixed infections



Recognize common artifacts

Recognize pseudoparasites

Recognize and identify other blood parasites

Learning objectives

Recognition of artifacts: stain deposits, dust, salts, scratches on slides

Recognition of pseudoparasites: fungi, bacteria

Recognition of mixed infections: thick and thin blood films

Recognition of other blood parasites: Borrelia species, trypanosomes, microfilariae, differences

from malaria parasites

Unit ❽ Microscopy quality assurance



Supportive supervision

Quality assurance

Quality control

Learning objectives

Explain the importance of supervision

Explain ways in which work can be supervised

Describe what must be provided for supervisors to allow them to supervise their work effectively

Describe methods of internal quality control for malaria microscopy

22

Unit ❾ The microscope



Using a binocular microscope

Major components of the microscope and how to use it

Maintenance and storage

Learning objectives

Demonstrate the correct set-up and use of a binocular microscope

Demonstrate correct use of the 10X paired oculars and 100X oil immersion objective

Operate the mechanical stage correctly

Name the ten major components of the microscope

Describe the correct way to maintain the microscope

Describe two ways of storing the microscope correctly

Demonstrate the correct way to pack the microscope for long distance transport

23

Annex 3. Resources

1. Ashraf S, Kao A, Hugo C, Christophel EM, Fatunmbi B, Luchavez J, Lilley K, Bell D. Developing

standards for malaria microscopy: external competency assessment for malaria microscopists in the

Asia-Pacific. Malaria Journal. 2012;11:352. doi: 10.1186/1475-2875-11-352.

https://malariajournal.biomedcentral.com/articles/10.1186/1475-2875-11-352.

2. World Health Organization (WHO). Basic Malaria Microscopy ‒ Part II: Tutor’s Guide. Second

Edition. Geneva: WHO; 2010. http://www.who.int/malaria/publications/atoz/924154791X/en/.

3. World Health Organization, Special Programme for Research and Training in Tropical Diseases.

Course Facilitators Guide: Training of Trainers on Malaria Diagnostic Testing using RDTs. Draft;

May 2013.

4. World Health Organization (WHO). Malaria Microscopy Quality Assurance Manual. Version 2.

Geneva: WHO; 2016. http://apps.who.int/iris/bitstream/10665/204266/1/9789241549394_eng.pdf.

https://malariajournal.biomedcentral.com/articles/10.1186/1475-2875-11-352

http://www.who.int/malaria/publications/atoz/924154791X/en/

http://apps.who.int/iris/bitstream/10665/204266/1/9789241549394_eng.pdf

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